Saving Meghan(57)

“And is that more or less than the rate of diagnosis at comparably sized hospitals?”

“I don’t know,” Zach said, sensing a tickle of worry dancing at the base of his neck. “Conservatively, I’d estimate the prevalence of mitochondrial disease in children is approximately one case per five hundred. So every minute, there’s a baby born somewhere that will develop the disease by age ten.”

The attorney returned a puzzled look, as if to say Zach’s numbers and her findings did not quite jibe.

“Your Honor, I’d like to move to introduce a document which shows that Dr. Fisher’s rate of diagnosis is double that of hospitals with a comparable patient population.”

The attorney presented the evidence to the judge, who glanced at it before setting it aside to allow the cross-examination to continue.

“Dr. Fisher, have you ever been accused of confirmation bias?” The attorney pulled her lips tight as she waited for an answer.

“Some have expressed concern that my past might be clouding my judgment, but those are accusations I’ve vehemently denied.”

“In Meghan’s case, did you do a muscle biopsy?” The attorney glanced down at her notes, making Zach think she had a laundry list of diagnostic measures to throw at him.

“No. It’s a somewhat painful procedure, and the patient has a severe needle phobia.”

“What about an electromyogram?”

“No, for the same reasons.”

“Did you do cerebral imaging?”

“No. I didn’t see it necessary to subject her to unnecessary radiation.”

“What about blood work?”

“Yes.”

“Even with Meghan’s needle phobia?”

“It wasn’t easy.”

“And the results?”

“Inconclusive,” Zach said regretfully.

Zach could not avoid a long discussion about heteroplasmy, a unique feature of deleterious mitochondrial DNA that was not present in Meghan’s samples, and why that was not a tell-all. He worried about losing the judge in technical jargon.

“Did you order genetic testing?”

“I did,” Zach said.

“And those results?”

“Inconclusive,” he said. “The gold standard here, if it could be called such, is the muscle biopsy, with which we would do additional genetic testing, as well as microscopic evaluation, enzyme testing, and so forth.”

“So why did you diagnose her with mito?”

“Given the patient’s needle phobia, I opted to rely on my clinical findings and other noninvasive observations to pursue a diagnosis. Oftentimes that’s equally as effective as other diagnostic measures. I was looking at a patient with a progressive disorder that involved multiple organ systems, fitting the disease criteria.”

“But then Meghan got new symptoms.”

“Yes, she did.”

“In your opinion, were those related to mito?”

“Mito is an unusual disease. The symptoms can be extremely variable from person to person, so it wouldn’t be out of the question, but my thought at the time was that it did not seem to fit the disease pattern as I know it.”

“What is the disease pattern as you know it?”

“Mitochondria produce ninety percent of the energy our body needs to function. The symptoms depend largely on which cells are affected, and the range of symptoms can be from mild to severe. Typically, the disease presents with muscle weakness, exercise intolerance, maybe some vision problems, fatigue. There can be GI issues as well, but what Meghan experienced at home was unusual given how the symptoms tend to occur more insidiously over time. But when Meghan came to the ER with sudden severe gastrointestinal issues and equally sudden vision problems, I became concerned.”

“So you referred the patient to Dr. Nash.”

“I did.” Zach flashed Amanda an angry look.

“And she came to a different conclusion?”

“I think that’s obvious,” he answered.

“Please answer the question yes or no,” the attorney stated flatly.

“Yes.”

The attorney scanned her notes. “One more question, Dr. Fisher,” she said. “Has an insurance company ever denied your claim for a mito cocktail with an inconclusive or negative result on a genetic panel for mitochondrial disease?”

Zach swallowed hard. “Yes. On a few occasions.”

“Could it be ten?” the attorney asked.

Zach thought before answering, though he did not need to. “It could be that.”

“And who paid for the continued treatment you prescribed despite the insurance company’s objections? The hospital or the patient?”

“Um—” Zack felt the full weight of Becky’s stare without having to look at her. “I explained to the parents the risks of stopping treatment. In most cases, the parents agreed to cover the cost.”

“But not all?”

“No,” Zach said. “Some of the patients’ parents were not able to meet the cost burden.”

“In that case, who paid?”

“The hospital, I believe, had to absorb the cost.” Zach thought he could see Knox Singer grinding his teeth.

“And why did the insurance companies deny payment for your prescribed treatment?” the attorney asked.